V-008 ROBOTIC TOTALLY EXTRAPERITONEAL RETROMUSCULAR REPAIR OF A TYPE III PARASTOMAL HERNIA

Aim

The retromuscular repair described by Pauli et al. (2016) dissects the retromuscular space, releases the transversus muscle, and lateralizes the stoma to place a retromuscular mesh. The aim was to show the results of the robotic approach for this intervention.

Material & Methods

Video description of a case report. The patient was a 71-year-old woman that underwent an abdominoperineal resection for rectal cancer in 2017 and presented with a 5.8 cm parastomal hernia without midline defects (type III of the EHS classification).

Results

Three robotic trocars were placed in the lateral of the right rectus sheath, and posteriorly a 12 mm assistance port was inserted in the left hypochondrium. The dissection began in the inferior preperitoneal space, until finding the left transversus muscle. Then, the rectus sheath was dissected superiorly and laterally. A posterior rectus sheath release was performed in a down–to–up direction, initially avoiding the parastomal hernia, which was later reduced. Posteriorly, the peritoneum was incised and then sutured to lateralize the stoma. The parastomal hernia defect and the posterior rectus sheath were equally sutured. Finally, a polyvinylidene difluoride (PVDF) mesh was placed in the retromuscular space, which was fixed with transfascial sutures to the sides of the stoma.

Conclusions

The robotic totally extraperitoneal retromuscular approach for parastomal hernias is safe and feasible, with the advantage of avoiding the intraperitoneal space.

P-086 MINIMALLY INVASIVE TREATMENT OF PARASTOMAL HERNIA: FROM THE LAPAROSCOPIC SANDWICH TECHNIQUE TO THE ROBOTIC RETROMUSCULAR TECHNIQUE

Aim

Parastomal hernias are frequent and highly recurrent. The sandwich technique (ST) (Berger et al. [2007]) uses a double intraperitoneal mesh, whereas the retromuscular technique (RMT) (Pauli et al. [2016]) dissects the retromuscular space, releases the transversus muscle, and lateralizes the stoma to place a retromuscular mesh. The aim was to evaluate the results of these interventions.

Matherial & Methods

Observational retrospective study of patients with parastomal hernia intervened by our Abdominal Wall Unit in a tertiary referral centre. The intervention performed was the ST from February 2016 to September 2020, and the RMT from September 2020 to March 2022.

Results

A total of 12 patients were intervened with the ST, eight laparoscopically and four robotically, and 7 patients were intervened with the RMT, all robotically. There were no statistically significant differences in basal characteristics between groups. According to the European Hernia Society classification, the parastomal hernias intervened in the ST were 16.7% type I, 33.3% type II, 16.7% type III, 33.3% type IV, while in the RMT most were type II (85.7%). The surgical time was more prolonged in the RMT.

There were no statistically significant differences in early complications. Long term follow-up was longer in the ST (median: 24 months vs. 1.6 months), and the recurrences observed were 25% (3/12) for ST and 14.3% (1/7) for RMT (p:1.000).

Conclusions

RMT is a challenging procedure with similar rate of early complications and promising relapse results despite a shorter follow-up. It is currently our procedure of choice for parastomal hernia.

P-068 RESULTS OF THE OPEN INTRAPERITONEAL ONLAY MESH TECHNIQUE WITH A PREFORMED PATCH FOR PRIMARY VENTRAL HERNIA AND INCISIONAL HERNIA

Aim

Primary ventral hernias and incisional hernias are frequent, but long–term results of their repair with a preformed patch are scarce. The aim was to evaluate the surgical results of the treatment of these hernias with the open intraperitoneal onlay mesh (open IPOM) technique, and to determine the needed follow–up for recurrence.

Material and methods

Observational retrospective single institution study of all consecutive patients intervened for ventral or incisional hernia with diameter inferior to 4 cm, from January 2013 to June 2020. The surgical repair was performed according to the open IPOM technique with a preformed patch and the defect was left unclosed. Relapsed hernias, those with a defect ≥ 4 cm, and lateral wall hernias were excluded.

Results

A total of 146 patients were intervened: 61.6% with umbilical hernias, 8.2% with epigastric hernias, 26.7% with trocar incisional hernias, and 3.4% with other incisional hernias.

The global recurrence rate was 7.5% (11/146). Specifically, there it was 7.8% in umbilical hernias, 0% in epigastric hernias, 7.7% in trocar incisional hernias, and 20% (1/5) in other incisional hernias. The median time for recurrence was 14 months (IQR: 4,4–18,7). The median presential follow–up was 17,4 months (IQR: 6,5–27,3), and the median telematic follow-up was 36,9 months (IQR: 27,2–49,6).

Conclusions

The open IPOM technique with a preformed patch offers good results for the treatment of ventral and incisional hernias. A 2-year follow-up is still needed for the recurrence diagnosis.

Note

The preformed patch used was the Parietex™ Composite Ventral Patch (Medtronic, Minneapolis, MN, EEUU).

V-028 USE OF ARTICULATED INSTRUMENTS IN EXTRAPERITONEAL ABDOMINAL WALL SURGERY

Introduction

One of the limitations in extraperitoneal abdominal wall surgery is the reduced range of movements of conventional instruments. The aim of this video was to show the advantages of articulated instruments.

Case presentation

The first case was a laparoscopic totally extraperitoneal (TEP) inguinal hernia repair of a direct bilateral hernia in a male patient. In this intervention the articulated grasper assisted with the isolation of the hernia sac and allowed to modify the direction of the traction during the dissection.

The second case was an extended totally extraperitoneal (eTEP) repair of a M3W2 incisional hernia associated to rectus diastasis in a female patient. The articulated instrument gave an increased traction adapted to the surface of the posterior rectus sheath and marked the limits for the section with the scissors.

Conclusion

The articulated instruments allowed an increased mobility in the extraperitoneal field.

Note: the articulated instruments were manufactured by IMM, Mannheim, Germany.

Guidelines for enhanced recovery after cardiac surgery. Consensus document of Spanish Societies of Anesthesia (SEDAR), Cardiovascular Surgery (SECCE) and Perfusionists (AEP)

The ERAS guidelines are intended to identify, disseminate and promote the implementation of the best, scientific evidence-based actions to decrease variability in clinical practice. The implementation of these practices in the global clinical process will promote better outcomes and the shortening of hospital and critical care unit stays, thereby resulting in a reduction in costs and in greater efficiency. After completing a systematic review at each of the points of the perioperative process in cardiac surgery, recommendations have been developed based on the best scientific evidence currently available with the consensus of the scientific societies involved.

Is there long-term value of pathology scoring in immunoglobulin A nephropathy? A validation study of the Oxford Classification for IgA Nephropathy (VALIGA) update

Background

It is unknown whether renal pathology lesions in immunoglobulin A nephropathy (IgAN) correlate with renal outcomes over decades of follow-up.

Methods

In 1130 patients of the original Validation Study of the Oxford Classification for IgA Nephropathy (VALIGA) cohort, we studied the relationship between the MEST score (mesangial hypercellularity, M; endocapillary hypercellularity, E; segmental glomerulosclerosis, S; tubular atrophy/interstitial fibrosis, T), crescents (C) and other histological lesions with both a combined renal endpoint [50% estimated glomerular filtration rate (eGFR) loss or kidney failure] and the rate of eGFR decline over a follow-up period extending to 35 years [median 7 years (interquartile range 4.1–10.8)].

Results

In this extended analysis, M1, S1 and T1–T2 lesions as well as the whole MEST score were independently related with the combined endpoint (P < 0.01), and there was no effect modification by age for these associations, suggesting that they may be valid in children and in adults as well. Only T lesions were associated with the rate of eGFR loss in the whole cohort, whereas C showed this association only in patients not treated with immunosuppression. In separate prognostic analyses, the whole set of pathology lesions provided a gain in discrimination power over the clinical variables alone, which was similar at 5 years (+2.0%) and for the whole follow-up (+1.8%). A similar benefit was observed for risk reclassification analyses (+2.7% and +2.4%).

Conclusion

Long-term follow-up analyses of the VALIGA cohort showed that the independent relationship between kidney biopsy findings and the risk of progression towards kidney failure in IgAN remains unchanged across all age groups and decades after the renal biopsy.

Actual incidence of prostate cancer in healthcare areas of the autonomous community of Castilla-Leon during 2014. CAPCYL registry data

OBJECTIVE

To determine the actual incidence of prostate cancer (PC) in the healthcare areas of Castilla-Leon in 2014.

MATERIAL AND METHODS

A multicentre study was conducted with the participation of 7 of the 9 healthcare areas of Castilla-Leon. We collected retrospective data that included 87.8% of the target population (men diagnosed with PC with histopathological confirmation in 2014). We calculated the raw and age-adjusted incidence rates based on the direct method and consulted the community and national epidemiological data in the Spanish National Institute of Statistics.

RESULTS

A total of 1198 new cases of PC were diagnosed, with a raw incidence rate in the community of 109.54 cases per 100,000 men. The adjusted rates for the Spanish and European populations were 115.41 and 110.07, respectively. The age group with the highest diagnostic concentration was the 60-70-year group, with 41.97% of the diagnoses. The group with the highest incidence was the 70-80-year group, with 438.87 cases per 100,000 inhabitants. There were differences in the raw and age-adjusted incidence rates and in the age at diagnosis among the various included healthcare areas.

CONCLUSIONS

The community raw incidence rate was higher than most existing data. We observed significant differences among the various geographical areas, which could be explained mainly by the age distribution and the opportunistic screening policies for each area.

Morphofunctional basis of the different types of angiogenesis and formation of postnatal angiogenesis-related secondary structures

We review the morpho-functional basis of the different types of angiogenesis and report our observations, including the formation of angiogenesis-related secondary structures. First of all, we consider the following issues: a) conceptual differences between angiogenesis and vasculogenesis, b) incidence of angiogenesis in pre- and postnatal life, c) regions of vascular tree with angiogenic capacity, d) cells (endothelial cells, pericytes, CD34+ adventitial stromal cells of the microvasculature and inflammatory cells) and extracellular matrix components involved in angiogenesis, e) events associated with angiogenesis, f) different types of angiogenesis, including sprouting and intussusceptive angiogenesis, and other angiogenic or vascularization forms arising from endothelial precursor cells (postnatal vasculogenesis), vasculogenesis mimicry, vessel co-option and piecemeal angiogenesis. Subsequently, we consider the specific morpho-functional characteristics of each type of angiogenesis. In sprouting angiogenesis, we grouped the events in three phases: a) activation phase, which includes vasodilation and increased permeability, EC, pericyte and CD34+ adventitial stromal cell activation, and recruitment and activation of inflammatory cells, b) sprouting phase, encompassing EC migration (concept and characteristics of endothelial tip cells, tip cell selection, lateral inhibition, localized filopodia formation, basal lamina degradation and extracellular changes facilitating EC migration), EC proliferation (concept of endothelial stalk cells), pericyte mobilization, proliferation, recruitment and changes in CD34+ adventitial stromal cells and inflammatory cells, tubulogenesis, formation of a new basal lamina, and vascular anastomosis with capillary loop formation, and c) vascular remodelling and stabilization phase (concept of phalanx cells). Subsequently, the concept, incidence, events and mechanisms are considered in the other forms of angiogenesis. Finally, we contribute the formation of postnatal angiogenesis-related secondary structures: a) intravascular structures through piecemeal angiogenesis, including intravascular papillae in vessel tumours and pseudotumours (intravascular papillary endothelial hyperplasia, vascular transformation of the sinus in lymph nodes, papillary intralymphatic angioendothelioma or Dabska tumour, retiform hemangioendothelioma, hemangiosarcoma and lymphangiosarcoma), vascular septa in hemorrhoidal veins and intravascular projections in some tumours; b) arterial intimal thickening; c) intravascular tumours and pseudotumours (e.g. intravenous pyogenic granulomas and intravascular myopericytoma); d) vascular glomeruloid proliferations; and e) pseudopalisading necrosis in glioblastoma multiform.

Should Asymptomatic Bacteriuria Be Systematically Treated in Kidney Transplant Recipients? Results From a Randomized Controlled Trial

The indication for antimicrobial treatment of asymptomatic bacteriuria (AB) after kidney transplantation (KT) remains controversial. Between January 2011 and December 2013, 112 KT recipients that developed one episode or more of AB beyond the second month after transplantation were included in this open-label trial. Participants were randomized (1:1 ratio) to the treatment group (systematic antimicrobial therapy for all episodes of AB occurring ≤24 mo after transplantation [53 patients]) or control group (no antimicrobial therapy [59 patients]). Systematic screening for AB was performed similarly in both groups. The primary outcome was the occurrence of acute pyelonephritis at 24-mo follow-up. Secondary outcomes included lower urinary tract infection, acute rejection, Clostridium difficile infection, colonization or infection by multidrug-resistant bacteria, graft function and all-cause mortality. There were no differences in the primary outcome in the intention-to-treat population (7.5% [4 of 53] in the treatment group vs. 8.4% [5 of 59] in the control group; odds ratio [OR] 0.88, 95% confidence interval [CI] 0.22-3.47) or the per-protocol population (3.8% [1 of 26] in the treatment group vs. 8.0% [4 of 50] in the control group; OR 0.46, 95% CI 0.05-4.34). Moreover, we found no differences in any of the secondary outcomes. In conclusion, systematic screening and treatment of AB beyond the second month after transplantation provided no apparent benefit among KT recipients (NCT02373085).

CHACO outreach project: the development of a primary health care-based medical genetic service in an Argentinean province

Dissemination of knowledge in genetics to be applied in medicine has created a growing need for capacity building in health care workers. The CAPABILITY ARGENTINA outreach project protocol was designed as a model to introduce genetics in areas without genetic services. Our aim was for genetic health care to become part of primary care in an Argentine province lacking genetic services. The program was innovative as professionals from the referral center (Garrahan Hospital S.A.M.I.C.) traveled to remote areas to train professionals through problem-based education. A logical framework was designed for a local needs assessment. Teaching materials (Powerpoint presentations, printed syllabus, and CD) and a web page were developed. A demonstration project was carried out in the Province of Chaco, Argentina. A total of 485 health workers were trained. The number of consultations increased significantly in participating areas comparing before and after the training period. To support this increase, a complementary project was set up from a public hospital sponsored from within Argentina to build a cytogenetic laboratory in the capital of the Province of Chaco. The model was improved for reproduction in other areas in Argentina. CAPABILITY ARGENTINA is a capacity building model for training of primary care professionals in genetics that may be applied to other medical specialties. The outcomes of the programme have a direct impact on clinical practice.

Epidemiology, risk factors and impact on long-term pancreatic function of infection following pancreas-kidney transplantation

Limited information exists about epidemiology and risk factors of infection following pancreas-kidney transplantation and its impact on long-term pancreatic graft function. A retrospective chart review of episodes of severe infection in consecutive pancreas-kidney transplantations in a single institution was performed to assess the epidemiology, risk factors for infection and their impact on the development of pancreatic graft dysfunction. Ninety-four (81%) of 116 recipients (median follow-up of 1492 days; mean 1594) developed 248 episodes of severe infection. Bacterial infections were present in 208 episodes, with 12% of the isolates resistant to antibiotics used in prophylaxis. There were 40 episodes of fungal infection in 32 patients (28%) (mostly Candida spp), and CMV disease appeared in 20 patients (17%), of which 50% appeared after the third month following surgery. The multivariate analysis identified that surgical re-intervention and the use of steroid pulses were independently associated with the development of any infection. Additionally, pre-transplant evidence of peripheral artery disease, a longer cold ischaemia time and high transfusional requirements were associated with fungal infections. Cytomegalovirus (CMV) mismatch was independently related to CMV disease and female sex, and bladder drainage of the exocrine pancreas was associated with urinary tract infection. At the end of follow-up, 29 patients (25%) had developed severe pancreatic graft dysfunction, and fungal infection was independently associated with it. Our study identifies a subset of pancreas-kidney transplant recipients at a higher risk of developing severe infection. Fungal infection is an independent risk factor for the development of severe pancreatic graft dysfunction.

SELECTION OF DONOR AND ORGAN VIABILITY CRITERIA: EXPANDING DONATION CRITERIA

Donation criteria have been becoming more flexible over the years. Currently, the only absolute exclusion criteria are human immunodeficiency virus infection (HIV), uncontrolled tumor disease and bacterial or viral infections. ClinicaL. conditions dictate organ viability criteria: biochemical, morphological and functional, that must be fulfilled by the donors and their organs in order to focus the decision on which donor organs can be used. These criteria attempt to assure that the transplanted organs function after the extraction, transformation, implantation and reperfusion process without transmitting any infectious or tumour disease. In recent years, the gross and microscopic appearance has become one of the fundamental criteria for selection of potentially viable organs. At present, there is no age limit for hepatic and renal donation; the principal contra-indication is chronic organ damage. The use of each organ must be decided individually after a profound analysis of all the viability criteria, weighing the advantages and disadvantages of the implant of a certain organ for the recipient.

A competing risks approach for time estimation of household WEEE disposal

The recent growth in the number of electrical and electronic devices is viewed as one the priority waste streams in European Union waste management policy. This paper presents the findings of a survey to study domestic habits with respect to Waste Electrical and Electronic Equipment (WEEE) in Spain. A specific problem when performing this estimation arises from the fact that consumers quite often store old appliances at home when they are no longer used. Focusing on four different types of appliance, survival analysis (SA) is used to study both the usage span and the reasons for no longer using each device. The time that the discarded products were kept at home before being disposed of was studied using competing risks (CR) analysis. The results of the analysis provide information on the distribution of the studied variables for the different outcomes as well as the influence exerted by the socio-demographic variables considered. Relations between these characteristics and the storage time of the appliances before disposal emerge based on survey data. For instance, the CR model finds that the storage time of the some appliances (i.e. refrigerator) is related to these social-demographics factors. However, other appliances (i.e. microwave oven) are less influenced by these factors. The attitude and motivation of the respondents to the survey as regards the End-of-Life of appliances were also analysed. A majority of respondents do not store discarded appliances at home. The first reason for storing appliances at home is the possibility of it being useful in the future and the second that the respondents did not know what to do with them.

High ambient temperature reverses hypothalamic MC4 receptor overexpression in an animal model of anorexia nervosa

The potential involvement of the melanocortin system in the beneficial effects of heat application in rats submitted to activity-based anorexia (ABA), an analogous model of anorexia nervosa (AN), was studied. Once ABA rats had lost 20% of body weight, half of the animals were exposed to a high ambient temperature (HAT) of 32 degrees C, whereas the rest were maintained at 21 degrees C. Control sedentary rats yoked to ABA animals received the same treatment. ABA rats (21 degrees C) showed increased Melanocortin 4 (MC4) receptor and Agouti gene Related Peptide (AgRP) expression, and decreased pro-opiomelanocortin (POMC) mRNA levels (Real Time PCR), with respect to controls. Heat application increased weight gain and food intake, and reduced running rate in ABA rats, when compared with ABA rats at 21 degrees C. However, no changes in body weight and food intake were observed in sedentary rats exposed to heat. Moreover, heat application reduced MC4 receptor, AgRP and POMC expression in ABA rats, but no changes were observed in control rats. These results indicate that hypothalamic MC4 receptor overexpression could occur on the basis of the characteristic hyperactivity, weight loss, and self-starvation of ABA rats, and suggest the involvement of hypothalamic melanocortin neural circuits in behavioural changes shown by AN patients. Changes in AgRP and POMC expression could represent an adaptative response to equilibrate energy balance. Moreover, the fact that HAT reversed hypothalamic MC4 receptor overexpression in ABA rats indicates the involvement of brain melanocortin system in the reported beneficial effects of heat application in AN. A combination of MC4 receptor antagonists and heat application could improve the clinical management of AN.

[The antiproteinuric effect of the blockage of the renin-angiotensin-aldosterone system (RAAS) in obese patients. Which treatment option is the most effective? ]

BACKGROUND

Obesity increases the risk of proteinuria and chronic renal insufficiency and hastens the progression of renal diseases. Increased activity of renin-angiotensin-aldosterone system and elevated levels of aldosterone are common in obese patients. No studies have compared the efficacy of the currently available antiproteinuric strategies (ACE inhibitors -ACEI-, angiotensin receptor blockers -ARB-, aldosterone antagonists) in obese patients with proteinuric renal diseases.

METHODS

Single centre, prospective, randomized study. Twelve obese patients (body mass index > 30 Kg/m2) with proteinuria > 0.5 g/24 h were selected from our outpatient renal clinic. Patients were consecutively treated during 6 weeks with an ACEI (lisinopril 20 mg/day), combined therapy ACEI+ARB (lisinopril 10 mg/day + candesartan 16 mg/day) and eplerenone (25 mg/day) in random order. A drug washout period of 6 weeks was established between the different treatment periods. The primary outcome point was the change in 24-h proteinuria at the end of each treatment period and the number of patients showing a proteinuria reduction greater than 25% of baseline.

RESULTS

The reduction in proteinuria induced by lisinopril (11.3+/-34.8%) was not statistically significant with respect to baseline, whereas that of lisinopril plus candesartan (26.9+/-30.6%) and eplerenone (28.4+/-31.6%) showed a statistically significant difference both with respect to baseline values and to lisinopril group. The number of patients who showed a greater than 25% proteinuria reduction was significantly higher with eplerenone (67%) and lisinopril+candesartan (67%) than with lisinopril (25%).

CONCLUSIONS

Monotherapy with an aldosterone antagonist and combination therapy with ACEI+ARB were more effective than ACEI monotherapy to reduce proteinuria in obese patients with proteinuric renal diseases.

[Floppy-iris syndrome associated with tamsulosin. A prospective case-control study]

OBJECTIVE

The main objectives of this study were: To assess the incidence of the intraoperative floppy-iris syndrome associated with tamsulosin and to analyse the incidence of intraoperative and postoperative complications as compared to a control group. Secondary objectives were: to describe the pupillary modifications associated with tamsulosin and to quantify the endothelial cell loss.

METHODS

A prospective review of 38 eyes of 38 patients was performed. Patients were assigned to two different groups. Group 1 (cases) included 19 eyes of 19 male patients taking tamsulosin, and group 2 (controls) included 19 eyes of 19 male patients not taking tamsulosin.

RESULTS

Only two patients (10%) of our study had the complete triad seen in floppy-iris syndrome; 9 patients (47%) showed 2 of the 3 main features of the syndrome and only 2 patients showed iris billowing during phacoemulsification. None of the patients in group 2 showed any of the characteristic intraoperative features. The complication rate was similar in both groups.

CONCLUSIONS

Intraoperative floppy-iris syndrome occurred in 67% of the patients treated with tamsulosin. The only postoperative secondary effect was a lower pupil reactivity in patients taking tamsulosin.

Is an emergency heart transplantation justified?

INTRODUCTION

Emergency heart transplantation remains an important controversy due to the shortage of donors and the previously demonstrated results inferior to other patients. These recipients display a worse clinical status and their donors are more often considered suboptimal. Nevertheless, it is the only therapeutic option for patients with advanced cardiomyopathy and acute decompensation with no response to other therapies. We compared results among the emergency indication with those of elective transplants.

METHODS

We analyzed the 213 patients who underwent cardiac transplantation in our center up to December 2004 to compare emergency with elective heart transplantations for preoperative and surgical variables as well as outcomes.

RESULTS

A higher percentage of emergency patients were New York Heart Association class IV, displayed renal dysfunction, and were women. Regarding donors, a higher percentage were over 40 years of age. No differences were observed in the early and first-year mortality or morbidity rates, although we noted a greater 5-year mortality rate among emergency cases.

CONCLUSIONS

In our center emergency heart transplantation was associated with only slightly worse results compared with elective transplantations. Both donors and recipients should be carefully selected to improve results.

[Glomerulopathies associated to HIV infection: a Spanish perspective]

HIV nephropathy (HIVAN) is the most frequent cause of chronic renal failure in HIV-infected black patients. However, the prevalence of other glomerulopathies mediated by immunocomplexes has increased in the last years. We report on the glomerular diseases observed in HIV patients in our Hospital.

METHODS

A retrospective study of all patients with HIV infection and glomerular diseases diagnosed by renal biopsy.

RESULTS

We found 27 patients with the following glomerular diseases: membranoproliferative glomerulonephritis (MPGN) in 8 patients, non-collapsing focal segmental glomerulosclerosis (FSGS) in 7, IgA nephropaty (IgA N) in 6, collapsing glomerulosclerosis in 4 (HIVAN, and membranous nephropaty (MN) in 2. Most of patients were young white men. A high prevalence of coinfection with hepatitis C virus (HCV) (77.8%) and hepatitis B virus (HBV) (37%) was found. At diagnosis, most of patients (90%) had proteinuria, with nephrotic syndrome in 52% of them; 59% presented with acute renal failure. Nine patients (33%) showed malignant hypertension at diagnosis: this complication was particularly common among IgA N patients (4/6, 66%).

CONCLUSION

In our Hospital, immunocomplex-mediated glomerulonephritis were more frequent than HIVAN among HIV-infected patients. HCV-associated MPGN was the most frequently detected glomerular disease. A high prevalence of malignant hypertension was observed at diagnosis, particularly among patients with IgAN.

Early handling reduces vulnerability of rats to activity-based anorexia

Resistance to restricted feeding with and without wheel access was tested in rats handled (H) for 20 days since birth. Weight loss produced by 1.5-hr restricted food access was less in H than in non-handled (NH) males when tested aged 41 days. At this age combining food restriction with access to a running wheel (a procedure commonly known as activity-based anorexia, ABA) produced very rapid weight loss and no effect of handling was detected. When 75-day females were tested in the same way, under the ABA procedure H rats took longer than NH controls to reach the removal criterion. Simply restricting food access in these females produced variable weight loss, without detection of any handling effect. No differences in food intake or running were detected between H and NH rats in either males or females. In conclusion, handling seems to have a direct effect on rats' later response to either food deprivation alone or to an ABA procedure.

Anti-CD25 Monoclonal Antibody Sequential Immunosuppressive Induction Therapy in Renal Transplants With High Risk of Delayed Graft Function

There is little experience on the use of monoclonal antibodies that block the high-affinity interleukin-2 receptor (basiliximab and daclizumab) in sequential therapy in renal transplants with risk of delayed graft function. This study sougth to test the efficacy and safety of the substitution of anticalcineurins with two doses of basiliximab or daclizumab in the immediate posttransplant period for recipients at risk of delayed renal graft function. Immunosuppression consisted of steroids, mycophenolate mofetil, and two doses of basiliximab (20 mg/day) on days 0 and 4 posttransplant or daclizumab (1 mg/kg per day) on days 0 and 15 posttransplant. Anticalcineurins were not administered until the beginning of graft function. Among 49 recipients (mean age 63.5 +/- 10.5 years), 40 received a kidney from a donor over 60 years of age, three from a non-heart-beating donor, and six from donors with an acute elevation of serum creatinine to 2.4 +/- 0.86 (1.7-3.7). At a mean follow-up of 14.2 +/- 8.4 months, five patients experienced acute rejection episodes. Only 15 patients needed posttransplant dialysis (2.7 +/- 1.6). In 11 patients, cyclosporine (CsA) was introduced at 6 +/- 2.9 days posttransplant and in 37, tacrolimus on 8.6 +/- 3.6 days posttransplant. The incidence of kidney graft loss was 16.3%. Patient survival was 96%. Thirty-nine recipients are alive with functioning grafts, with mean serum creatinine of 1.4 mg/dL. In conclusion, substitution for anticalcineurins with interleukin-2-receptor blockade in the immediate posttransplant period for patients at risk of delayed graft function minimizes nephrotoxicity and reduces tubular necrosis, without increasing the risk of an acute rejection episode.

Tacrolimus as Basic Immunosuppression in Pregnancy After Renal Transplantation. A Single-Center Experience

Renal transplantation restores fertility within an average of 6 months, so women of childbearing age are able to consider pregnancy. Successful pregnancies have been reported in recent years under different immunosuppressive regimens, but the optimal treatment to achieve the maximum safety for both the mother and fetus remains unclear. Tacrolimus has been demonstrated to provide long-term immunosuppression and prevent rejection in most renal transplants. It seems safe, but experience is limited compared with cyclosporine. We report our experience highlighting the high rate of successful pregnancies attained in women treated with tacrolimus as the basic immunosuppressant and advised of recommendations to achieve a healthy newborn. Renal function was preserved during the pregnancy. The puerperal period and the rate of gestation-related difficulties appeared similar to that of the general population.

Analysis of worldwide earthquake mortality using multivariate demographic and seismic data

In this paper, mortality in the immediate aftermath of an earthquake is studied on a worldwide scale using multivariate analysis. A statistical method is presented that analyzes reported earthquake fatalities as a function of a heterogeneous set of parameters selected on the basis of their presumed influence on earthquake mortality. The ensemble was compiled from demographic, seismic, and reported fatality data culled from available records of past earthquakes organized in a geographic information system. The authors consider the statistical relation between earthquake mortality and the available data ensemble, analyze the validity of the results in view of the parametric uncertainties, and propose a multivariate mortality analysis prediction method. The analysis reveals that, although the highest mortality rates are expected in poorly developed rural areas, high fatality counts can result from a wide range of mortality ratios that depend on the effective population size.

[Digestive haemorrhage due to angiodysplasia in dialysis patients. Treatment with conjugated estrogens]

Gastrointestinal angiodysplasia is a very common cause of digestive hemorrhage among elderly patients with chronic renal insufficiency. Therapeutic possibilities are scarce, as well as information available. Here we present our experience with 8 cases of dialysis patients that were treated with conjugated estrogens because of digestive hemorrhage due to angiodysplasia. Dissapearance of bleeding was observed after the onset of estrogen therapy, with a significant decrease of blood transfusions. This type of non-invasive treatment can avoid aggressive therapeutic interventions in patients with a high prevalence of co-morbid conditions (old patients undergoing chronic dialysis).

[Treatment of steroid-dependent minimal change-nephrotic syndrome with mycophenolate mofetil]

Here we report two male patients, 16 and 20 years-old respectively, with minimal-change nephrotic syndrome showing frequent relapses and steroid dependence. Treatment with cyclosporin did not prevent the appearance of new relapses and both patients developed cyclosporin-dependence. The introduction of mycophenolate mofetil (500-15,000 mg/day) was followed by a sustained complete remission in both cases, without secondary effects.

[Antiproteinuric effect of renin-angiotensin system blockade in patients with normal/lower than 115 mmHg systolic blood pressure]

The renoprotective effect of renin-angiotensin system (RAAS) blockade by ACE inhibitors (ACEI) or AT1 receptor antagonists (ARA) in chronic proteinuric nephropathies is well known. Most studies have related this beneficial effect with the antihypertensive and antiproteinuric properties of these drugs, but this aspect has not been extensively analyzed in patients with normal/low values of blood pressure. We studied nineteen patients with different chronic proteinuric nephropathies that started ACEI or ARA because of proteinuria and despite systolic blood pressure (SBP) < or = 115 mmHg. Short and long-term tolerance to treatment as well as evolution of renal function parameters were recorded.

RESULTS

At baseline, SBP was 110.2 +/- 2.6 mmHg (105-115) an diastolic blood pressure (DBP) 68.6 +/- 4.3 (60-75). Initial low doses of ACEI or ARA were well tolerated. After 6 months of treatment, proteinuria decreased by 46% of baseline, from 2.1 +/- 1.8 g/day to 1.1 +/- 0.8 g/day, without significant changes in BP or renal function. After a 48 +/- 27 months follow up, proteinuria decreased to 0.7 +/- 0.6 g/day (68% of basal values). Renal function and BP did not show significant changes during follow up.

CONCLUSIONS

RAAS blockade by ACEI/ARA induces a significant antiproteinuric and renoprotective effect in proteinuric patients with normal/low levels of BP Initial doses of ACEI/ARA were well tolerated.

[Acute hyperphosphatemia secondary to phosphate administration for bowel preparation]

We report a 75-years-old woman, stable on a three-weekly hemodialysis program over a period of 3 years, who develop acute hyperphosphatemia secondary to phosphate administration for bowel preparation. The quick clinical diagnosis and the treatment with intensive hemodialysis resulted in a correction of hyperphosphatemia, hypocalcemia, acidemia and other electrolyte abnormalities. The phosphate cathartics are contraindicated in patients with severe renal insufficient or in dialysis program. Our case shows the severe side effects secondary to injudicious use of sodium phosphate cathartics.

[Membranoproliferative glomerulonephritis associated with autoimmune thyroiditis]

Several cases of glomerular disease have been associated to thyroid diseases. The most frequent lesion described is membranous glomerulopathy, presented as a nephrotic syndrome. Here we report a 67-year-old man who developed a nephrotic syndrome accompanied by rapid derangement of renal function shortly after the onset of a primary hypothyroidism due to autoimmune thyroiditis. High titers of circulating anti-thyroglobulin and anti-microsomal thyroid antigen antibodies were detected. Serum levels of C3 and C4 fractions of complement were markedly decreased. Renal biopsy showed a membranoproliferative glomerulonephritis with severe mesangial proliferation, a type of glomerular involvement non-described previously in the literature, in relation with thyroid diseases. Four boluses of intravenous steroids were administered, followed by oral prednisone for three months. A dramatic recovery of renal function, together with normalization of urinary sediment, proteinuria decrease and normalization of serum complement were observed. Three years later, the patient suffered from a similar event, with a positive response to steroids again. One year later, the patient had a new recurrence and was treated with mycophenolate mofetil , improving his clinical situation.

Results of kidney transplantation in recipients over 70 years of age: experience at a single center

We performed 41 kidney transplants in patients >70 years (35 single and 6 dual), with a mean recipient age of 72+/-2 years, from January 1990 to December 2001. Mean age of the donors was 69+/-12 years. Immunosuppression used triple therapy with steroids, mycophenolate mofetil, and cyclosporine or tacrolimus. Cold ischemia time was 23+/-3 hours. The incidence of primary nonfunction was 4.8%, and delayed graft function 58.5%. Acute rejection incidence was 12%. The actuarial patient survival rates at 12, 24, and 36 months were 82.5%, 82.5%, and 75%, respectively. Actuarial survival rates of the grafts censuring for death of the recipient with a functioning graft were 89.5%, 86%, and 68%, respectively. Nine of the 18 graft losses were due to recipient death. Overall, renal transplant recipients >70 years showed good results. The principal cause of graft loss was recipient death.

[Immunoallergic interstitial nephritis vs. cholesterol atheroembolism. Differentiating characteristics]

The commonest clinical presentation of both immunoalergic interstitial nephritis (IIN) and atheroembolic renal disease (ATD) is an acute renal failure accompanied by skin lesions and eosinophilia. As a consequence, differential diagnosis between both entities is often very difficult. We have performed a comparative retrospective study of those patients diagnosed as having IIN or ATD in our Hospital in the period 1980-2000. A total of 42 patients have been diagnosed of IIN and 16 of ATD. Demographic data, as well as clinical and laboratory parameters and outcomes of every studied patient were analysed. We found a significantly higher prevalence of male sex (100% vs 57%, p < 0.01), previous history of hypertension (100% vs 55%, p < 0.01), chronic renal insufficiency (56% vs 17%, p < 0.01), ischemic heart disease (56% vs 14%, p < 0.001), peripheral ischemic disease, endovascular procedures (87% vs 7%, p < 0.001) and anticoagulant treatments (25% vs 5%, p < 0.001) among patients with ATD as compared with IIN, respectively. On the contrary, previous infections (45% vs 12%, p < 0.01) and exposure to new drugs (100% vs 40%, p < 0.001) were significantly more frequent among IIN patients in compare with ATD. ATD patients showed skin lesions consisting of livedo reticularis and digital infarcts (63% vs 31%, p < 0.05) accompanied by blood pressure increase (100% vs 24%, p < 0.001), whereas IIN patients showed fever (41% vs 19%, p < 0.05) and cutaneous rash as significant clinical manifestations, respectively. The number of ATD patients with proteinuria > 1 g/24 h was significantly higher, but no differences between both groups in the prevalence of urinary sediment abnormalities were observed. The prevalence of absolute eosinophilia was high in both groups (88% among ATD patients, 64% among IIN patients; pNS). Prognosis of both entities was clearly different: Almost all patients with ATD died (69%) or evolved to end-stage renal failure, whereas most patients with IIN showed a recovery of renal function after withdrawal of responsible drugs and steroid treatment. In summary, the analysis of clinical and laboratory data allows an initial differential diagnosis in patients suspected as having IIN or ATD.

[Evaluation of methods to calculate dialysis dose in daily hemodialysis]

Daily dialysis has shown excellent clinical results because a higher frequency of dialysis is more physiological. Different methods have been described to calculate dialysis dose which take into consideration change in frequency. The aim of this study was to calculate all dialysis dose possibilities and evaluate the better and practical options. Eight patients, 6 males and 2 females, on standard 4 to 5 hours thrice weekly on-line hemodiafiltration (S-OL-HDF) were switched to daily on-line hemodiafiltration (D-OL-HDF) 2 to 2.5 hours six times per week. Dialysis parameters were identical during both periods and only frequency and dialysis time of each session were changed. Time average concentration (TAC), time average deviation (TAD), normalized protein catabolic rate (nPCR), Kt/V, equilibrated Kt/V (eKt/V), equivalent renal urea clearance (EKR), standard Kt/V (stdKt/V), urea reduction ratio (URR), hemodialysis product and time off dialysis were measured. Daily on-line hemodiafiltration was well accepted and tolerated. Patients maintained the same TAC although TAD decreased from 9.7 +/- 2 in baseline to a 6.2 +/- 2 mg/dl after six months, p < 0.01. No significant changes were observed in weekly Kt/V and eKt/V throughout the study. However EKR, stdKt/V and weekly URR were increased during D-OL-HDF in 24-34%, 46% and 50%, respectively. Hemodialysis product was raised in a 95% and time off dialysis was reduced to half.

CONCLUSION

Dialysis frequency is an important urea kinetic parameter which there are to take in consideration. It's necessary to use EKR, stdKt/V or weekly URR to calculate dialysis dose for an adequate comparison between different frequency dialysis schedules.

Translation, cross-cultural adaptation, and validation of the Bath Ankylosing Spondylitis Functional Index (BASFI), the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and the Dougados Functional Index (DFI) in a Spanish speaking population with spondyloarthropathies

OBJECTIVES

The Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), the Bath Ankylosing Spondylitis Functional Index (BASFI) and the Dougados Functional Index (DFI) are the most commonly used instruments to measure disease activity and functioning in ankylosing spondylitis (AS). The aim of this study was to translate, adapt and validate these instruments into the Spanish language.

METHODS

The BASDAI, BASFI, and DFI questionnaires were translated into Spanish by three independent bilingual physicians who were familiar with the medical aspects of AS and by one professional translator. Two rheumatologists familiar with instrument validation, and who were aware of the purpose of the study, examined semantic, idiomatic and conceptual issues and produced by consensus unified versions of each instrument. English back-translations from the Spanish were done by a professional translator unaware of the original version. Both English versions were compared, and where needed, modifications to the Spanish versions were made. The Spanish versions were administered to 61 ambulatory patients with AS and to 80 patients with undifferentiated spondyloarthropathy for validation purposes. Reliability and responsiveness were measured in 28 patients participating in a physiotherapy program.

RESULTS

Reliability showed an acceptable 24-hour test-retest intraclass correlation coefficient (ICC)--BASFI ICC: 0.68, 95% CI: 0.29-0.85; BASDAI ICC: 0.74, 95% CI: 0.52-0.88 and DFI ICC: 0.87, 95% CI: 0.73-0.94. The construct validity of the instruments was evaluated, and BASDAI was correlated with disease activity measured by the total enthesis count (rs: 0.34); general well being in the last week (rs: 0.7); spinal pain (rs: 0.53) and duration of morning stiffness (rs: 0.64). BASFI correlated with Schöber's test (rs: -0.4); occipital-wall distance (rs: 0.38) and thoracic expansion (rs: -0.3). DFI correlated with Schöber's test (rs: -0.36); occipital-wall distance (rs: 0.29) and chest expansion (rs: -0.3). The correlation among DFI and BASFI was rs: 0.83. All instruments showed clinical responsiveness in the physiotherapy program (baseline and end of program; mean +/- SD): BASDAI: 6.25 +/- 1.97 and 3.07 +/- 2.04 (p = 0.0001); BASFI: 5.68 +/- 2.29 and 2.88 +/- 1.77 (p = 0.0001); DFI: 16 +/- 7.6 and 8.0 +/- 5.5 (p = 0.001) with effect sizes and standardized effect sizes > 1.

CONCLUSIONS

The Mexican Spanish versions of the BASDAI, BASFI, and DFI showed adequate reliability, validity and responsiveness to clinical change. These instruments can be used in the clinical evaluation of Spanish-speaking patients with AS.